Provider Demographics
NPI:1487249132
Name:FASANO, AVA (RDN)
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:AVA
Other - Middle Name:
Other - Last Name:REICHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4937 REMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-1375
Mailing Address - Country:US
Mailing Address - Phone:484-860-7840
Mailing Address - Fax:
Practice Address - Street 1:3080 HAMILTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3692
Practice Address - Country:US
Practice Address - Phone:484-661-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10187133V00000X
PADN008234133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered